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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />OWNER! OPERATOR <br />I- \\. S t (CI S s !\'-')-1 A <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />SITE ADDRESS <br />1 7 17-7 Street Number Direction <br />GA I Street Name <br />-TRACY <br />City <br />9S--3 0 \A <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />a (2 (2-) V -Q. Street Number Street Name <br />Crry STATE ZIP <br />PHONE #1 ExT. <br />CLJ5 ) q t 4 - -lc 5 G <br />APN #,z4s, <br />1 Ott qo LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT 5.----- LOCATION C9DE ty <br />(---i 7 <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />/\ apoviz__ CHECK if BILLING ADDRESS <br />BUSINESS NAME PHONE # EXT. / <br />(tog) 7 ILI- zo s- & <br />HomE or MAILING ADDRESS FAX # <br />( ) <br />CITY STATE ZIP <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site ancUor project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br />or activity will be billed to me or my business as identified on this form. <br />I also certify that I have prepared this a plication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, TAT L laws. <br />APPLICANT'S SIGNATURE: <br />PROPERTY BUSINESS OWNER': OPERATOR / MANAGER 0 <br />DATE: <br />OTHER AUTHORIZED AGENT 0 <br />6170-1 <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: tiel, <br />, <br />()71. /m_c-H-Iii IP,() -, <br />COMMENTS: <br />cf. __......" <br />i /Otis <br />, 42, <br />84,0;?'0 4/1,i, <br />DATE: <br />. <br /> . ... . ACCEPTED BY: i 6, / f /lj 1/1-'S , <br />EMPLOYEE #: CD/15 <br />ASSIGNED TO: ...S <br />r <br />EMPLOYEE #: <br />PC-S <br />DATE: .../..7--/Z 0 <br />Date Service Completed (if already completed): 8 /5(7 ( SERVICE CODE: C Z. PIE: Li. 2.6) ;2' <br />Fee Amount: 57 Amount Paid <br />1 9-C2 <br />Payment Date <br />-721 <br />Payment Type Invoice # -etrualr / Rec ived By: <br />2cogf(2--e-P SR FORM (Golden Rod) EHD 48-02-025 <br />REVISED 11/17/2003